REVOCATION OF PAYROLL DEDUCTION
VOLUNTARY PAYROLL DEDUCTION TO A STATE AGENCYAgency Name: FORMTEXT ??????Agency Address: FORMTEXT ??????Street FORMTEXT ?????? FORMTEXT ?? FORMTEXT ?????CityStateZip CodeAgency Phone #: FORMTEXT ??????Agency Fax:Agency Contact:Employee Name: FORMTEXT ?????Banner ID Number: FORMTEXT ?????Employee Address: FORMTEXT ?????Street FORMTEXT ?????? FORMTEXT ?? FORMTEXT ?????CityStateZip CodeDepartment: FORMTEXT ????I hereby authorize the State of Illinois or SIUE to deduct from my earnings $ FORMTEXT ?????each pay period and continuous until revoked. I reserve the right to revoke this authorization at any time by submitting a written Revocation form. This deduction is to be in accordance with the established rules of the State Salary and Annuity Withholding Act. FORMCHECKBOX Faculty FORMCHECKBOX Staff (paid Semi-monthly) FORMCHECKBOX Staff (paid Bi-weekly)Effective Pay Period FORMTEXT ?????(Deduction will take affect when Agency removes your account from the offset list.)Signature:Date: HR ONLY Processed By:Date Faxed to Agency:Deduction Code:PWRAGCY ID ................
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